Predictors of Phantom Limb Pain, Psychological Factors and Chronic Musculoskeletal Pain Following Traumatic Lower-Limb Amputation: The Impact of Delayed Rehabilitation Services

Background: Phantom limb pain, poor sleep, musculoskeletal pain, and psychological distress are common in patients following traumatic lower-limb amputations. Nevertheless, there is still a lack of research on the connections between these variables and rehabilitation service accessibility. Evidence on phantom limb pain and related rehabilitation factors remains limited in conflict-affected settings, where access to timely prosthetic and rehabilitation services may be substantially disrupted. Objective: The study aimed to determine the prevalence of phantom limb pain and chronic musculoskeletal pain, and to assess their correlation with sleep quality, depression, anxiety and access to rehabilitation services in individuals with traumatic lower-limb amputation. Methods: Between August 2025 and April 2026, 491 patients with unilateral traumatic lower-limb amputations who were receiving outpatient rehabilitation services participated in the study. The Pittsburgh Sleep Quality Index was used to measure sleep quality, while the Hospital Anxiety and Depression Scale was used to measure anxiety and depression. In addition, participants reported delays in physiotherapy and prosthetic fitting, phantom limb pain, and chronic musculoskeletal pain. Mann–Whitney U tests were used for group comparisons, while multiple regression analysis and Spearman correlations were used to assess the relationships. Results: Phantom limb pain was reported by 78.8% of participants, while 46.2% experienced chronic musculoskeletal pain. Among patients who had not received a prosthesis, the mean delay to prosthetic provision was 472.9 days, while the median delay was 502 days. Poorer sleep quality (β = 0.480, p < 0.001) and longer delays to prosthetic fitting (β = 0.184, p = 0.002) were independently associated with greater phantom limb pain intensity. Participants with chronic musculoskeletal pain and those who had not received a prosthesis experienced poorer sleep quality, greater depression and anxiety, and more severe phantom pain than participants without musculoskeletal pain and those who had received a prosthesis. Conclusions: Phantom limb and chronic musculoskeletal pain are highly prevalent after lower-limb amputation. Delayed prosthetic fitting and sleep disturbances are associated with greater phantom pain.